White Coat Underground » PalMDhttp://scienceblogs.com/whitecoatunderground
Just another siteTue, 20 Jul 2010 21:27:41 +0000en-UShourly1http://wordpress.org/?v=4.1.1We’ve moved!http://scienceblogs.com/whitecoatunderground/2010/07/20/weve-moved/
http://scienceblogs.com/whitecoatunderground/2010/07/20/weve-moved/#commentsTue, 20 Jul 2010 21:27:41 +0000http://scienceblogs.com/whitecoatunderground/2010/07/20/weve-moved/You can follow me at the old-new location. Just follow this link. There I will keep you annoyed, entertained, and updated. You can also grab my new feed there.
]]>http://scienceblogs.com/whitecoatunderground/2010/07/20/weve-moved/feed/0Ethics and goals: always a challengehttp://scienceblogs.com/whitecoatunderground/2010/07/19/ethics-always-a-challenge/
http://scienceblogs.com/whitecoatunderground/2010/07/19/ethics-always-a-challenge/#commentsMon, 19 Jul 2010 16:05:37 +0000http://scienceblogs.com/whitecoatunderground/2010/07/19/ethics-always-a-challenge/My formal ethical training began in medical school with an introduction to the basic concepts of medical ethics. This training continued as I encountered difficult cases and thought through them, often with the help of the hospital ethics committee. While I haven’t continued my formal education in ethics, I’ve continued my own reading, and I enjoy writing on ethical conundrums.

I’ve been blogging now for over three years, which, in internet time, is quite a while. During that time, I’ve begun to take the writing itself more and more seriously. I’ve begun to recognize the implications of the medium itself, especially in conversations with mainstream journalists. We bloggers are, for better or worse, part of “the media”. So I’ve had to learn something about journalism ethics as well.

This has changed the way I write. When I look back at some of my earliest posts, I cringe. In many ways that’s a good thing; as it turns out, I have the ability to learn and improve. My commenters and my colleagues help keep me honest, and without them, I’d write just as poorly as I did five years ago. I’ve also expanded the type of writing I do. In addition to my always well-reasoned rantings and my discussions of science-based medicine, I’ve done some more investigative pieces, interviewing sources, and consulting other journalists about ethics and approaches.

Given that much of my writing is very critical of unethical medical practices, I don’t have a lot of wiggle room in my own public behavior. This isn’t to say that to be ethical is to be perfect; far from it. But behaving ethically is hard work that involves hard decisions, and frequent mistakes.

ScienceBlogs has not made such a mistake. With the mishandling of the launch of a commercial ad-blog, Seed Media Group showed incompetence and mismanagement. They also showed that they do not consider themselves (or we bloggers) to be “media” or journalists. Whether we like it or not, we are the media, and while we may enjoy a great deal more freedom in style and content than most mainstream media, we cannot claim immunity from their ethics.

It is for these reasons (and others, most of which have been eloquently and completely laid out by Bora Zivkovic) that I’m leaving ScienceBlogs, something I do with great regret. I have gained immeasurably from my association with Sb and with the people here. It has given me incredible opportunities. But despite the advantages in exposure, the fit just isn’t good anymore.

This is a personal decision, not one that can be generalized to include anyone writing here. The bloggers here are some of my favorite science writers, and always will be, whether they remain at Sb or go elsewhere. I have nothing but respect and admiration for them.

]]>http://scienceblogs.com/whitecoatunderground/2010/07/19/ethics-always-a-challenge/feed/41Sunday morning reflectionshttp://scienceblogs.com/whitecoatunderground/2010/07/18/sunday-morning-reflections/
http://scienceblogs.com/whitecoatunderground/2010/07/18/sunday-morning-reflections/#commentsSun, 18 Jul 2010 08:58:02 +0000http://scienceblogs.com/whitecoatunderground/2010/07/18/sunday-morning-reflections/The Midwest loves extremes. Our spring is a quick, cold bucket of water to the face, and the fall a brief but intense set of umber and auburn brush strokes on the landscape. Today is neither of those, but still, hot, and humid enough to make breathing uncomfortable. So I’m looking out the window, rather than sitting outside, and I see something heartening: a crow.

I’ve noticed—really noticed—the crows and blue jays this year. Several years ago, when I was a young attending physician, the hospital seemed filled with a new ailment. The victims were often elderly, had high fevers, paralysis, confusion; they often died, or were left permanently disabled. There were younger people too, but they usually had a bad headache and a fever which resolved without incident. That’s when the crows and jays died.

They died in huge numbers. On a hike with my parents, I found a dead crow lying in the middle of the path, an experience that would be repeated over and over. The bird had succumbed to West Nile Virus, as had a number of my patients.

I haven’t seen a serious case of West Nile in years. I’ve seen suspected mild cases, but I wasn’t about to do a spinal tap to find out for sure. And this year, the crows and jays are everywhere. West Nile is probably a regular part of our hot, humid summers, although we don’t see the same number of severe cases that we saw in that first year. Still, when the sun sets, and the temperature becomes bearable outside, I am much more aware of each mosquito buzzing around my ankles.

]]>http://scienceblogs.com/whitecoatunderground/2010/07/18/sunday-morning-reflections/feed/3Reminder: Whooping cough is serious businesshttp://scienceblogs.com/whitecoatunderground/2010/07/16/i-should-never-see-a/
http://scienceblogs.com/whitecoatunderground/2010/07/16/i-should-never-see-a/#commentsFri, 16 Jul 2010 16:05:32 +0000http://scienceblogs.com/whitecoatunderground/2010/07/16/i-should-never-see-a/I shouldn’t see any cases of pertussis (“whooping cough”), but I do. We have a safe, effective and affordable vaccine. But still, people are getting this disease. In the age group I see (adults), immunity has often waned, and if they haven’t been revaccinated, they can get the disease and pass it on. In adults it often looks like a cold, but not in kids. Most properly vaccinated children are immune and remain so until there little airways are large enough to cope with the illness. But a certain percentage of kids either don’t get vaccinated or aren’t successfully vaccinated, leaving them vulnerable to a disease that shouldn’t even exist at a measurable rate.

In small children, with their little airways, pertussis often leads to hospitalization, and not infrequently kills. It kills children who should never have been put at risk, either because their parents refused to vaccinate them, or people around them did and gave them the disease.

Children and adults who should be vaccinated but are not represent a public health failure, and in the case of parents who deny their kids the vaccine, an ethical failure as well.

As a reminder, this is what pertussis looks like in little kids.

]]>http://scienceblogs.com/whitecoatunderground/2010/07/16/i-should-never-see-a/feed/54Important reads you may be missinghttp://scienceblogs.com/whitecoatunderground/2010/07/16/important-reads-you-may-be-mis/
http://scienceblogs.com/whitecoatunderground/2010/07/16/important-reads-you-may-be-mis/#commentsFri, 16 Jul 2010 11:11:50 +0000http://scienceblogs.com/whitecoatunderground/2010/07/16/important-reads-you-may-be-mis/Since the Pepsipocalypse, several excellent science writers (some of the best, really) have sought out new homes online. You really shouldn’t miss them.

SciCurious: special shout out to Sci who is one of the best pseudonymous science writers out there, and if she were under her real name would probably be one of the best non-pseudonymous science writers

]]>http://scienceblogs.com/whitecoatunderground/2010/07/16/important-reads-you-may-be-mis/feed/2Would this work in Kansas?http://scienceblogs.com/whitecoatunderground/2010/07/15/would-this-work-in-kansas/
http://scienceblogs.com/whitecoatunderground/2010/07/15/would-this-work-in-kansas/#commentsThu, 15 Jul 2010 14:08:37 +0000http://scienceblogs.com/whitecoatunderground/2010/07/15/would-this-work-in-kansas/Catherine Shoichet, a reporter at CNN, is reporting on a unique (as far as I know) public health intervention. For a few bucks, a randy Switzer can have a three pack of condoms delivered by bike in one hour.

How cool is that?

]]>http://scienceblogs.com/whitecoatunderground/2010/07/15/would-this-work-in-kansas/feed/11Rostropovich and Richterhttp://scienceblogs.com/whitecoatunderground/2010/07/14/rostropovich-and-richter/
http://scienceblogs.com/whitecoatunderground/2010/07/14/rostropovich-and-richter/#commentsWed, 14 Jul 2010 20:44:32 +0000http://scienceblogs.com/whitecoatunderground/2010/07/14/rostropovich-and-richter/I credit my youngest sister for introducing me to these guys playing this piece, but it might have been my father. I’ve listened to several different musicians playing this, and none matches these two. None.

The vid starts in the middle, but it’s still worth watching Rostropovich make the cello weep.

]]>http://scienceblogs.com/whitecoatunderground/2010/07/14/rostropovich-and-richter/feed/2HuffPo blogger claims skin cancer is conspiracyhttp://scienceblogs.com/whitecoatunderground/2010/07/14/huffpo-blogger-claims-skin-can/
http://scienceblogs.com/whitecoatunderground/2010/07/14/huffpo-blogger-claims-skin-can/#commentsWed, 14 Jul 2010 17:31:28 +0000http://scienceblogs.com/whitecoatunderground/2010/07/14/huffpo-blogger-claims-skin-can/I was a bit torn when trying to figure out how to approach this piece. A reader emailed me about an article in the Huffington Post, and there is so much wrong with it that I felt overwhelmed. My solution is to focus on a few of the problems that can help illuminate broader points.

There is a small but vocal movement of people who refuse to believe that skin cancer caused by sunlight is a significant health risk. These people tend to also believe that the risk is being purposely hyped by others, and that our current approach to skin cancer prevention is causing an epidemic of vitamin D deficiency. Leaving aside the seemingly insane denialism regarding sunlight and cancer, there are two broad problems with this article. The first is pretty bad.

With the summer months upon us I wanted to find out firsthand what exactly the mantra is that dermatologists are telling patients. So I went undercover to several San Francisco dermatologists in order to see if there is legitimate concern about the sun-scare media hype. Are these doctors being sensible or going overboard when it comes to advice on sunscreen use and skin cancer prevention? Is the sky falling with dangerous UV rays or are we being induced into a media panic?

He goes on to give links to recorded conversations, and prints out partial transcripts. He does not specify whether or not he received permission to record these conversations, as required by California law. Whether or not the law requires it, the writer should have disclosed to his readers whether or not he had received permission. This information is important in interpreting the conversations he reports to us.

The next problem is broader, and deals with physicians’ willingness to lie on behalf of patients. The author’s presumably-clandestine recordings of his deceptive visits to dermatologists (catching my breath—this is striking and requires a digression. The act of deceiving these doctors is not only unethical, but can influence the outcome of the visit. Doctors make the assumption that most patients are interacting with them out of good faith, and are not intentionally deceiving them.)

In the first conversation the author has with a doctor, the interviewer makes it clear that he wants a mole removed, and the doctor essentially leads him to say “the right thing” so that insurance will cover the procedure. One thing the author seems to miss is that the dermatologist is going to be paid whether or not insurance covers the procedure. If the insurance company says “no”, the patient will be billed. The doctor is lying for the patient, not for herself.

Data have shown that physicians are willing to lie on behalf of patients. There are a number of reasons that this poses ethical problems. It could be argued that the doctor is lying to help get the patient something that they need, and that lying is a peccadillo compared to the benefit. This can backfire in a number of ways, not least of which is that both the doctor and the patient can probably be prosecuted for fraud, something that is unlikely to be of benefit to either one.

But there is a fine line between a lie and a truth, one that anyone familiar with the intimacies of the exam room will often experience. As a doctor, your overall impression may be that the patient is at high risk for coronary artery disease, but perhaps the patient doesn’t quite meet the insurance company’s criteria. You can then lay out the cost of the test and the risks and benefits for the patient, but I wouldn’t be surprised if some doctors took the short cut of asking, “are you sure you’ve never had any chest pain or difficulty breathing?”

He begins his second dermatology visit by telling the doctor that he has a family history of melanoma, and finds fault in the doctor’s description of the statistics of the disease. The problem of properly rendering statistics is a common one, and he links to an excellent piece by Ivan Oransky explaining the difference between relative risk and absolute risk. Unfortunately, he uses this to spin a tale of some sort of dermatology conspiracy to inflate cancer numbers. Skin cancers (including melanomas and non-melanoma skin cancers) are very, very common, and though many are not fatal, their diagnosis and treatment can be expensive and disfiguring.

His visit continues and the doctor tells him that insurance won’t cover his mole removal because it’s not necessary, and refuses to lie in the medical record. The doc then gives some sound medical advice about how to prevent skin cancers.

I then ask what measures I should take to prevent skin cancer. I’m told to apply sunscreen 24/7, wear a hat and sunglasses, as well as avoid the sun as much as possible. (The only thing she doesn’t mention is to live underground with the mole people.)

“Mole people”? He asked the doc how to prevent skin cancer, the doc gave the correct answer. It’s up to the patient to decide if the application of sunscreen is too onerous for the potential benefit.

This article shows a misunderstanding of journalistic ethics, medical ethics, and medical science. It’s a disaster. And it’s no surprise that it’s in the Huffington Post.

]]>http://scienceblogs.com/whitecoatunderground/2010/07/14/huffpo-blogger-claims-skin-can/feed/18Casals plays Bachhttp://scienceblogs.com/whitecoatunderground/2010/07/12/casals-plays-bach/
http://scienceblogs.com/whitecoatunderground/2010/07/12/casals-plays-bach/#commentsMon, 12 Jul 2010 19:05:58 +0000http://scienceblogs.com/whitecoatunderground/2010/07/12/casals-plays-bach/Bach’s first solo cello suite looks deceptively simple on the page. It doesn’t call for virtuosity as such, but to sound like more than an étude requires someone like Pablo Casals.

]]>http://scienceblogs.com/whitecoatunderground/2010/07/12/casals-plays-bach/feed/13What is an internist and why should you care?http://scienceblogs.com/whitecoatunderground/2010/07/12/what-is-an-internist-and-why-s/
http://scienceblogs.com/whitecoatunderground/2010/07/12/what-is-an-internist-and-why-s/#commentsMon, 12 Jul 2010 10:00:23 +0000http://scienceblogs.com/whitecoatunderground/2010/07/12/what-is-an-internist-and-why-s/Yes, this is a repost, sort of. I first put this up on denialism blog in December of 2008. For various reasons, I haven’t had a chance to crank out anything fresh this weekend, but this is still a good one, and I’ve edited it to freshen it up a bit, so don’t complain until you read it. –PalMD

It’s July again, and that means I have a crop of new interns. I love new interns, because every topic is fresh, every moment a teaching moment. I’m sobered by the statistic that predicts that only about 4% of American medical grads will chose primary care, but even when I work with the subspecialty transitional interns, I get to give them a dose of medical education. It’s interesting to watch this final class before the new ACGME rules take effect next July. This weekend, they were busy, and they looked tired post-call. That classic post-call look may turn out to be a thing of the past.

No matter what changes we ultimately make in the way we train internists, one of the lessons that residency teaches is to identify who is truly sick. I don’t mean who is faking it, I mean being able to look at someone briefly and decide whether or not they need your immediate attention. It may seem obvious, but it’s not. Objective factors can sometimes be deceiving. For example, an asthmatic may have perfectly normal vital signs, including a normal oxygen level, and yet be moments away from needing a breathing machine. For an asthmatic, a normal respiratory rate may indicate fatigue rather than health, and absence of wheezing my indicate such severe airway obstruction that wheezes aren’t even possible. The ability to recognize severe illness is one of the critical goals of residency.

This is one area in which the so-called alternative medicine folks can really be dangerous.

One time, we had a middle aged guy come into the clinic. He looked like crap. He was too thin, too weak, too pale, and too breathless. To me, it was obvious that he was seriously ill. But at a brief glance, I’m not so sure a layperson would make that same judgment. None of the individual factors was really strong enough: yes, he was pale, but so are a lot of people; yes he was thin, but maybe that’s natural for him. But when my residents and I saw him, we were fairly certain that he had TB or AIDS or cancer and that he was approaching a crisis that might kill him. We immediately admitted him to the hospital.

But that’s not what his previous health care provider did. He saw a doctor (licensed DO or MD, not sure which) who told him something about his glands not working well, and gave him supplements. When the patient got sicker, the doctor changed him to some different supplements. This isn’t only a failure of an individual doctor to recognize an individual sick patient. It is a failure of a doctor to know how to think like a doctor.

One of my professors was fond of saying that the best internist on TV was Colombo, and while that dated him a bit, the point got through. A good internist can form an immediate impression of illness vs. health, but there’s obviously more. First she meets a patient, takes a thorough history, does a complete physical, and develops what is called a “differential diagnosis”, or a list of potential explanations for the patient’s condition. The internist then uses the data she knows to guide her to further studies, and she will cross potential diagnoses off the list as the data come in. For example, the patient above was short of breath. Physical exam did not reveal any abnormal lung or heart sounds, so pneumonia and heart failure seemed unlikely. His oxygen level was good, so lack of oxygen reaching the blood (indicating a problem likely at the level of the alveoli) seemed unlikely. A blood test showed a very low blood count. This seemed likely to be the proximate cause of his breathlessness, but for a real doctor, that’s not good enough.

The type of anemia is very important—is it from blood loss, and if so, is it acute, sub-acute, or chronic? Is it hemolytic, meaning blood cells are being destroyed? Is it due to inhibition of normal blood cell production? A good look at a blood smear can help sort this out, as can a look at additional labs. A real internist will not be satisfied giving someone “Adrenal Max” or “Energy Boost Plus”, or some such nonsense.

The reason an internist wouldn’t just give a magic potion isn’t just because she doesn’t believe in magic. It’s because magic potions wouldn’t even cross her mind. It isn’t relevant to human health and disease. What is relevant is the patient, their illness, what science says is and isn’t plausible, and what medicine has found to be effective or ineffective. The doctor who gave the energy pills wasn’t right—he wasn’t even wrong. He was thinking so far outside the box, that he didn’t need to know anything about the patient or about medical science in order to prescribe the treatment. The thinking was a simplistic “energy low, give so-called energy pill”.

A friend of mine who is a lawyer was talking to me about a similar case recently and said, “why isn’t that fraud?” I didn’t have a good answer.